Four ways communities are turning health care delivery on its head

By Philip Caper, M.D.Bangor Daily News, Feb. 15, 2012

When veteran print and TV journalist T.R. Reid visited Maine last fall, he claimed we could provide health care for everybody and do it for less money with better results. At 3:30 p.m. Sunday, the Maine Public Broadcasting Network will air his latest documentary, “U.S. Health Care: The Good News,” which shows how it can be done. [PNHP note: The documentary premieres Feb. 16 on PBS. Check local listings.]

We spend almost $3 trillion nationwide on health care, about twice the average of all other wealthy nations. Our health care system has plenty of problems, but a shortage of money is not one of them. Historically, we in the U.S. have responded to problems in health care by throwing money at them. This mountain of money has led to a lot of wasteful spending.

High health care costs have raised taxes and insurance premiums, depressed wages and eroded public budgets. The more money we pump into our health care system, the worse it seems to get.

We spend so much because we have the highest prices for products and services in the world and often overuse them. Experts estimate that 30 percent of health care services provided in the U.S. offer little or no benefit to patients.

At the same time, we provide too few services to others. More than 50 million Americans, including 125,000 Mainers, lack coverage, and many more are inadequately insured. Underinsured people tend to put off medical care until they become very ill, often forcing them to go to the emergency room where the expense is far greater. Someone else usually pays the bill.

We learn in Reid’s documentary that costs often are driven more by a community’s supply of health care facilities and technology than by the amount of illness, contributing to large geographic differences in health care spending.

Our patchwork system of public and employment-based private insurance is inherently inefficient. There are literally thousands of insurance plans and tens of thousands of different policies in the U.S., all with different rules. Insurance companies spend megabucks trying to deny claims, and doctors, hospitals and patients spend more trying to get paid. This imposes hundreds of billions of dollars in administrative costs nationwide, with few or no medical benefits.

With so many private insurers, each one has little power to bargain down the prices charged by increasingly bottom-line-driven health care providers. Doctors and hospitals attempt to maximize their revenues by skewing their mix of services toward those that are most profitable, sometimes doing unnecessary procedures. Product manufacturers try to maximize their prices and generate demand, shamelessly peddling their goods to the public. While the insurance and health care industries game the system, patients pay the costs in more ways than one.

Each of these problems presents an opportunity to do more with less.

But tinkering with the status quo will not fix the problem. Reid suggests some promising solutions from several U.S. communities that have some important features in common.

First, they cover everybody in one communitywide insurance program. This facilitates preventive care, treats everyone by the same rules, cuts administrative costs and dramatically increases the public’s sense of fairness, community and confidence in the system. Recent changes in Maine law that will increase the number of companies in the state selling insurance go in the opposite direction.

Second, they put the whole array of services, from the ICU to home health care, within an organized system under a global budget — the only effective way to control overall costs. In Maine, Eastern Maine Healthcare Systems has been chosen to pilot a similar system for Medicare beneficiaries, a system that if proven cost effective could spread across the state.

Third, they reduce financial incentives that unduly influence clinical decisions. Fee-for-service payment to health caregivers is replaced by systems such as salaries and bonuses, eliminating the pressure on providers to chase dollars by doing expensive but unnecessary tests and procedures and giving them more time to spend with their patients.

Finally, they return the culture of health care to its healing mission and away from its excessive focus on the bottom line. As one doctor Reid interviews puts it, “Collaborate, do the right thing, don’t be greedy and work not out of self-interest but in the community interest.”

If these changes were easy, they would have been made already. But if they are made, we can provide health care for everybody at less cost. If they can do it in Washington state, Colorado and New Hampshire, we can do it in Maine. That really is good news.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.